Similar Post-transplant Survival Research Articles

Outcomes of Liver Transplant for Hepatic Epithelioid Hemangioendothelioma.

Hepatic epithelioid hemangioendothelioma (HEH) is a rare indication of liver transplant with limited evidence. Adult recipients undergoing first-time liver-only transplant from 2002 to 2021 in the United States were identified using the UNOS/OPTN database. We compared post-transplant outcomes of recipients receiving liver transplant for HEH versus other diagnoses. Survival was visualized using Kaplan-Meier curves and compared using log-rank test and multivariable Cox regression. Propensity score matching for recipient age, sex, and MELD was performed, with baseline characteristics and survival compared between groups. Of 111 558 liver transplant recipients identified, 121 (0.1%) underwent transplant for HEH. Donors to HEH recipients were more often living donors. Recipients with HEH were younger, more likely to be female, and had lower BMI. Recipients with HEH had higher albumin, lower bilirubin, lower INR, and lower serum creatinine, as well as lower MELD scores and rates of ascites and encephalopathy. Similar post-transplant survival was observed for recipients with HEH (16.6 [lower 95% CI 14.9] years) and non-HEH diagnoses (13.8 [95% CI 13.6-13.9] years, log-rank p = 0.28), even after adjusting for baseline donor and recipient characteristics (aHR 1.28 [95% CI 0.94-1.74], p = 0.12). The propensity score matched cohort also had similar post-LT survival. This national study represents the largest known report on liver transplant for HEH. The survival of recipients with HEH was similar to other etiologies, supporting the use of liver transplantation (LT) in advanced HEH.

Association of Community Socioeconomic Distress With Waitlist and Survival Outcomes in Liver Transplantation.

Despite efforts to ensure equitable access to liver transplantation (LT), significant disparities remain. Although prior literature has considered the effects of patient sex, race, and income, the contemporary impact of community socioeconomic disadvantage on outcomes after waitlisting for LT remains to be elucidated. We sought to evaluate the association of community-level socioeconomic deprivation with survival after waitlisting for LT. All waitlisted candidates for isolated LT were identified using the 2005-2023 Organ Procurement and Transplantation Network. The previously validated Distressed Communities Index, representing poverty rate, median household income, unemployment, business growth, education level, and housing vacancies, was used to characterize community socioeconomic distress. Zip codes in the highest quintile were classified as the "distressed" cohort (others: "nondistressed"). Kaplan-Meier and Cox proportional hazard models were applied to assess patient and graft survival. We performed a Fine and Gray competing risk regression to consider the impact of distress on waitlist mortality. Of 169 601 patients, 95 020 (56%) underwent LT and 74 581 (44%) remained on the waitlist. Among transplanted patients, 18 774 (20%) were distressed. After adjustment, distressed faced similar posttransplant survival at 1 y but greater mortality hazard at 5 y (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.04-1.12) and 10 y (HR, 1.09; 95% CI, 1.05-1.12). Considering all waitlisted patients, competing risk analysis demonstrated distressed candidates to face significantly greater cumulative incidence of death/deterioration on the waitlist (HR, 1.07; 95% CI, 1.04-1.11). Community-level socioeconomic inequity is associated with greater waitlist mortality and inferior post-LT survival. Novel interventions are needed to address structural barriers to care and continued inequities in outcomes.

A Global Experience of Donation after Circulatory Death for Pediatric Lung Transplantation.

Donation after circulatory death (DCD) lung transplantation has increased, but there is limited data in children. We sought to characterize the international experience of pediatric DCD lung transplant (LT) in comparison to donation after brain death (DBD) to address extreme donor organ shortages in children needing LT. Using the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Organ Transplant Registry, 1453 children (<18yo) LT recipients from January 2004 to June 2018 were identified: 34 (3%) were DCD and 1419 (97%) were DBD recipients. Post-transplant outcomes were compared between groups. Propensity score method was used to derive matched cohorts and were compared between groups. DCD and DBD recipients were of similar age, with cystic fibrosis being the most frequent indication for LT in both groups (64.5% vs. 57.5%, respectively). Kaplan-Meier analysis demonstrated similar survival between DCD and DBD cohorts, whereas propensity score-matched recipients also identified similar post-transplant survival in both groups (P=0.098). Secondary analysis found that DCD LT recipients had a longer post-transplant length of hospital stay (unmatched cohorts: 36.5d vs. 20d, p=0.022; matched cohort: 26d vs. 19d, p=0.016), and shorter time to acute cellular rejection (ACR) (unmatched cohorts: 248d vs. 560d, p=0.039; matched cohorts: 248d vs. 1650d,p=0.059). Due to DCD being a key contributor to the increasing number of lung transplants being performed worldwide, the results of this analysis support this organ donation approach in children requiring LT, which would increase access to donor organs. The identification of a potential shorter time to ACR needs further exploration as more DCD pediatric LTs are performed.

Donation after circulatory death significantly reduces waitlist times while not changing post–heart transplant outcomes: A United Network for Organ Sharing Analysis

ObjectiveRecently, several centers in the US have begun performing donation after circulatory death (DCD) heart transplants (HT) in adults. We sought to characterize the recent use of DCD HT, waitlist-time, and outcomes compared to donation after brain death (DBD). MethodsUsing the UNOS database, 10,402 adult (>18yo) HT recipients from January 2019-June 2022 were identified: 425(4%) were DCD and 9,977(96%) were DBD recipients. Post-transplant outcomes in matched and unmatched cohorts, and waitlist-times were compared between groups. ResultsDCD and DBD recipients had similar age [57y for both, p=0.791]. DCD recipients were more likely white (67% vs. 60%,p=0.002), on LVAD (40% vs. 32%,p<0.001) & listed as status 4-6 (60% vs. 24%,p<0.001); however, less likely to require inotropes (22% vs. 40%,p<0.001), & preoperative ECMO (0.9% vs. 6%,p<0.001). DCD donors were younger (29 vs. 32y,p<0.001), had less renal dysfunction (15% vs. 39%,p<0.001), diabetes (1.9% vs. 3.8%,p=0.050) or hypertension (9.9% vs. 16%,p=0.001). In matched & unmatched cohorts, early survival was similar (p=0.22). Adjusted waitlist-time was shorter in DCD group (21d vs. 31d,p<0.001) compared to DBD cohort and 5-fold shorter (DCD-22d vs DBD-115d,p<0.001) for candidates in status 4-6 which was 60% of DCD cohort. ConclusionsThe community is using DCD mostly for those recipients who are expected to have extended wait list times (e.g., Durable LVADs, Status >4). DCD recipients had similar post-transplant early survival, and shorter adjusted waitlist-time compared to DBD group. Given this early success, efforts should be made to expand the donor pool using DCD, especially for traditionally disadvantaged recipients on the waitlist.

Donation after circulatory death improves probability of heart transplantation in waitlisted candidates and results in post-transplant outcomes similar to those achieved with brain-dead donors

ObjectiveTo quantitate the impact of heart donation after circulatory death (DCD) donor utilization on both waitlist and post-transplant outcomes in the United States. MethodsThe United Network for Organ Sharing database was queried to identify all adult waitlisted and transplanted candidates between October 18, 2018, and December 31, 2022. Waitlisted candidates were stratified according to whether they had been approved for donation after brain death (DBD) offers only or also approved for DCD offers. The cumulative incidence of transplantation was compared between the 2 cohorts. In a post-transplant analysis, 1-year post-transplant survival was compared between unmatched and propensity-score-matched cohorts of DBD and DCD recipients. ResultsA total of 14,803 candidates were waitlisted, including 12,287 approved for DBD donors only and 2516 approved for DCD donors. Overall, DCD approval was associated with an increased sub-hazard ratio (HR) for transplantation and a lower sub-HR for delisting owing to death/deterioration after risk adjustment. In a subgroup analysis, candidates with blood type B and status 4 designation received the greatest benefit from DCD approval. A total of 12,238 recipients underwent transplantation, 11,636 with DBD hearts and 602 with DCD hearts. Median waitlist times were significantly shorter for status 3 and status 4 recipients receiving DCD hearts. One-year post-transplant survival was comparable between unmatched and propensity score–matched cohorts of DBD and DCD recipients. ConclusionsThe use of DCD hearts confers a higher probability of transplantation and a lower incidence of death/deterioration while on the waitlist, particularly among certain subpopulations such as status 4 candidates. Importantly, the use of DCD donors results in similar post-transplant survival as DBD donors.

Current status and future potential of ex vivo lung perfusion in clinical lung transplantation.

Lung transplantation is accepted as a well-established and effective treatment for patients with end-stage lung disease. While the number of candidates added to the waitlist continues to rise, the number of transplants performed remains limited by the number of suitable organ donors. Ex vivo lung perfusion (EVLP) emerged as a method of addressing the organ shortage by allowing the evaluation and potential reconditioning of marginal donor lungs or minimizing risks of prolonged ischemic time due to logistical challenges. The currently available FDA-approved EVLP systems have demonstrated excellent outcomes in clinical trials, and retrospective studies have demonstrated similar post-transplant survival between recipients who received marginal donor lungs perfused using EVLP and recipients who received standard criteria lungs stored using conventional methods. Despite this, widespread utilization has plateaued in the last few years, likely due to the significant costs associated with initiating EVLP programs. Centralized, dedicated EVLP perfusion centers are currently being investigated as a potential method of further expanding utilization of this technology. In the preclinical setting, potential applications of EVLP that are currently being studied include prolongation of organ preservation, reconditioning of unsuitable lungs, and further enhancement of already suitable lungs. As adoption of EVLP technology becomes more widespread, we may begin to see future implementation of these potential applications into the clinical setting.

126 - Ph-Positive ALL Patients Who Are Treated with Tyrosine Kinase Inhibitors Have Similar Post-Transplant Survival As Ph-Negative Patients

126 - Ph-Positive ALL Patients Who Are Treated with Tyrosine Kinase Inhibitors Have Similar Post-Transplant Survival As Ph-Negative Patients

Expected effect of the lung Composite Allocation Score system on US lung transplantation

Efforts are underway to transition the current lung allocation system to a continuous distribution framework whereby multiple factors are simultaneously combined into a Composite Allocation Score (CAS) to prioritize candidates for lung transplant. The purpose of this study was to compare discrete CAS scenarios with the current concentric circle-based allocation system to assess their potential effects on the US lung transplantation system using the Scientific Registry of Transplant Recipients' thoracic simulated allocation model. Six alternative CAS scenarios were compared over 10 simulation runs using data from individuals on the lung transplant waiting list from January 1, 2018, through December 31, 2019. Outcome measures were transplant rate, count, waitlist deaths, posttransplant deaths within 2 years, donor-to-recipient distance, and percentage of organs predicted to have flown. Across scenarios, waitlist deaths decreased by 36% to 47%, with larger decreases in deaths at lower placement efficiency weight and higher weighting of the waitlist outcomes. When waitlist outcomes were equally weighted to posttransplant outcomes, more transplants occurred in individuals with the highest expected posttransplant survival. All CAS scenarios led to improved overall measures of equity compared with the current Lung Allocation Score system, including reduced waitlist deaths, and resulted in similar posttransplant survival.

Abstract 15813: Comparative Case Series of Biventricular Support Between Heartmate-3 Ventricular Assist Devices and the Total Artificial Heart: A Single-Center Experience

Introduction: Currently, only the Syncardia Total Artificial Heart (TAH) is approved for biventricular support as a bridge-to-transplant (BTT). The off-label use of continuous flow ventricular assist devices (VAD) in a biventricular configuration (BiVAD) has been used with variable results, emphasizing the need for patient selection. We report our single-center BiVAD experience in patients supported with two HeartMate-3 (HM-3) VADs in a biventricular configuration in comparison with TAH support. Methods: All patients receiving durable biventricular mechanical support at The Mount Sinai Hospital (New York, New York) were considered. Baseline clinical, echocardiographic, hemodynamic and outcome data were extracted. Outcomes of interest were postoperative survival and adverse events, and compared using non-parametric statistics. Successful BTT and post-transplant survival were descriptively evaluated. Results: From November 2018 through May 2022, a total of 6 (37.5%) patients received two HM-3 VAD pumps in a BiVAD configuration and 10 (62.5%) patients received a TAH. Overall, TAH patients had significantly higher median INTERMACS profiles (p &lt; 0.05) at baseline compared to those on HM-3 BiVAD support but lower 30-day and 6-month survival and with a significantly higher rate of renal failure (Table 1). However, survival declined to the same rate at 1-year with both forms of support and was largely due to extracardiac adverse events related to underlying comorbidities (particularly, CKD/ESRD and diabetes, p &lt; 0.05). Successful BTT has thus far been achieved in 2 (33%) HM-3 BiVAD compared to 5 (50%) TAH patients, and had similar post-transplant survival at 1-year. Conclusions: HM-3 BiVAD demonstrated lower short-term and similar long-term mortality compared to TAH support among patients in extremis. However, larger studies are needed to optimize patient selection and pursuit of mechanical support in biventricular failure.

Association of Donors With US Public Health Service Risk Criteria and Outcomes After Adult vs Pediatric Cardiac Transplant

The United Network for Organ Sharing (UNOS) evaluates donor risk for acute transmission of HIV, hepatitis B, or hepatitis C based on US Public Health Services (PHS)-specific criteria. However, recent data regarding use and outcomes of those donors with PHS risk criteria among pediatric and adult heart transplant recipients are lacking. To compare use and outcomes of graft from donors with PHS risk criteria vs those with a standard-risk donor (SRD) in children vs adults in a contemporary cohort. This cohort was a nationwide analysis of heart transplants in the US that used data from the UNOS database. Participants were children (<18 years old) and adults (≥18 years old) who received a heart transplant from January 1, 2010, to December 31, 2021. UNOS-defined donor risk status. Trend analysis compared changes in PHS risk criteria use among children and adults. Patient survival was analyzed using Kaplan-Meier curves with log rank and Cox proportional hazards to compare PHS risk-criteria outcomes vs SRD-criteria outcomes in children and adult heart transplant recipients. Additional analysis was performed among adults who received a PHS-risk criteria graft that was previously declined for pediatric recipients. Of 5115 pediatric transplant recipients (donor without PHS risk median [IQR] age, 5 [0-13] years and donor with PHS risk median [IQR] age, 8 [0-14] years) and 30 289 adult heart transplant recipients (donor without PHS risk median [IQR] age, 56 [46-63] years and donor with PHS risk median [IQR] age, 57 [47-63] years), PHS risk criteria comprised 8% in children vs 25% in adults. PHS criteria are being increasingly used over the past decade with the proportion of recipients transplanted with PHS risk-criteria donors being approximately 3 times greater among adult recipients than children recipients. Pediatric recipients of a PHS risk-criteria donor had greater pretransplant ventilatory support, whereas adult recipients of a PHS risk-criteria donor had greater pretransplant extracorporeal membrane oxygenation use. Patient survival was similar between pediatric recipients of PHS risk-criteria grafts vs SRD-criteria grafts and slightly higher among adult recipients of PHS risk-criteria grafts vs SRD-criteria grafts. The 1778 adult recipients who received a PHS criteria-risk donor that was previously declined for pediatric recipients had similar patient survival recipients compared with SRD-criteria donors (HR, 0.92; 95% CI, 0.81-1.03; P = .18). In the current era, a 3-fold greater proportion of adult recipients receive a PHS risk-criteria graft compared with children despite similar posttransplant patient survival. The ongoing organ donor shortage underscores the need for consideration of PHS risk criteria where these donors remain underused.

Double-lung versus heart-lung transplantation for end-stage cardiopulmonary disease: a systematic review and meta-analysis.

We compared posttransplant outcomes following double-lung transplantation (DLTx) and heart-lung transplantation (HLTx), based on a search of PubMed, Cochrane Library, and Embase, from inception to March 8, 2022, for studies that report outcomes of these procedures. We then performed a meta-analysis of baseline characteristics and posttransplant outcomes. Subgroup analyses were implemented according to indication, publication year, and center. This study was registered on PROSPERO (number CRD42020223493). Ten studies were included in this meta-analysis, involving 1230 DLTx patients and 1022 HLTx patients. The DLTx group was characterized by older donors (P = 0.04) and a longer allograft ischemia time (P < 0.001) than the HLTx group. The two groups had comparable 1-year, 3-year, 5-year, 10-year survival rates (all P > 0.05), with similar results identified in subgroup analyses. We found no significant differences in 1-year, 5-year, and 10-year chronic lung allograft dysfunction (CLAD)-free survival, length of intensive care unit stay and hospital stay, length of postoperative ventilation, in-hospital mortality, or surgical complications between the groups (all P > 0.05). Thus, DLTx provides similar posttransplant survival to HLTx for end-stage cardiopulmonary disease. These two procedures have a comparable risk of CLAD and other posttransplant outcomes.

Preserved Post-transplant Survival in Highly Sensitized Patients Who Received Hepatitis C NAAT Positive Allografts. A UNOS Database Analysis

<h3>Introduction</h3> Highly sensitized heart transplant candidates have a longer waitlist time, worse waitlist outcomes and often require higher levels of immunosuppression post-transplantation. Expanding the heart transplant donor pool with Hepatitis C NAAT positive (Hep C NAAT (+)) donors could increase the chances of transplantation in highly sensitized patients. The effects of sensitization on post-transplant outcomes in patients who received Hep C NAAT (+) donor allografts is unknown. <h3>Methods</h3> Adult patients who received HT from a Hep C NAAT (+) donor, between May 2015 and Dec 2020, were identified from the United Network for Organ Sharing (UNOS) database. These patients were classified according to the percentage of panel reactive antibody (PRA): Non-sensitized (0%), mildly sensitized (0%-20%), Moderately sensitized (21%-50%), and highly sensitized (>50%). Clinical characteristics and post-transplant survival were compared between groups. <h3>Results</h3> A total of 831 patients received HT from a hep C NAAT (+) donor during the study period. Of these 605 (72.8%), 88 (10.6%), 70 (8.4%) and 68 (8.2%) patients were non-sensitized, mildly sensitized, moderately sensitized, and highly sensitized, respectively. Highly sensitized patients were more likely to be women and African American. The 360-day post-transplant survival was 90.8%, 92.1%, 92.7%, 93% for the non-sensitized, mildly, moderately, and highly sensitized groups, respectively (p =ns). The frequency of graft failure (p= 0.97), acute rejection (p=0.193) and coronary vasculopathy (p=0.51) were similar among groups. <h3>Conclusions</h3> Highly sensitized patients who received Hepatitis C NAAT positive allografts have similar post-transplant survival than non-sensitized patients. Thus, highly sensitized patients should not be excluded from the donor pool expansion offered by hepatitis C NAAT positive donors.

Offer Acceptance Patterns for Liver Donors Aged 70 and Older.

Despite a documented survival benefit, older liver donor (OLD, age ≥70) graft offers are frequently declined, with utilization worsening over the last decade. To understand how offer acceptance varies by center, we studied 1113 eventually transplanted OLD grafts from 2009 to 2017 using Scientific Registry of Transplant Recipients (SRTR) data and random-intercept multilevel logistic regression. To understand how center-level acceptance of OLD graft offers might be associated with waitlist and posttransplant outcomes, we studied all adult, actively listed, liver-only candidates and recipients during the study period using Poisson regression (transplant rate), competing risks regression (waitlist mortality), and Cox regression (posttransplant mortality). Among 117 centers, OLD offer acceptance ranged from 0 (23 centers) to 95 acceptances, with a median odds ratio of 2.88. Thus, a candidate may be three times as likely to receive an OLD graft simply by listing at a different center. Centers in the highest quartile (Q4) of OLD acceptance (accepted 39% of OLD offers) accepted more nationally shared organs (Q4 versus Q1: 14.1% versus 0.0%, P<0.001) and had higher annual liver transplant volume (Q4 versus Q1: 80 versus 21, P<0.001). After adjustment, nationally shared OLD offers (adjusted odds ratio [aOR]: 0.16, 95% confidence interval [CI]: 0.13-0.20) and offers to centers with higher median Model for End-Stage Liver Disease (MELD) at transplant (aOR: 0.74, 95% CI: 0.62-0.87) were less likely to be accepted. OLD offers to centers with higher annual transplant volume were more likely to be accepted (aOR: 1.21, 95% CI: 1.14-1.30). Additionally, candidates listed at centers within the highest quartile of OLD graft offer acceptance had higher deceased donor liver transplantation (DDLT) rates (adjusted incidence rate ratio: 1.45, 95% CI: 1.41-1.50), lower waitlist mortality (adjusted subhazard ratio: 0.76, 95% CI: 0.72-0.76), and similar posttransplant survival (adjusted hazard ratio: 0.93, 95% CI: 0.86-1.01) when compared with those listed at centers in the lowest quartile of OLD graft offer acceptance. The wide variation in OLD offer acceptance supports the need for optimizing the organ offer process and efficiently directing OLD offers to centers more likely to use them.

Donation After Circulatory Death Is Associated With Similar Posttransplant Survival in All but the Highest-Risk Hepatocellular Carcinoma Patients.

Liver transplantation (LT) recipients with hepatocellular carcinoma (HCC) receive a higher proportion of livers from donation after circulatory death (DCD) donors compared with non-HCC etiologies. Nevertheless, data on outcomes in patients with HCC receiving DCD grafts are limited. We evaluated the influence of DCD livers on post-LT outcome among HCC patients. We identified 7563 patients in the United Network for Organ Sharing (UNOS) database who underwent LT with Model for End-Stage Liver Disease score exceptions from 2012 to 2016, including 567 (7.5%) who received a DCD donor organ and 6996 (92.5%) who received a donation after brain death (DBD) donor organ. Kaplan-Meier probabilities of post-LT HCC recurrence at 3years were 7.6% for DCD and 6.4% for DBD recipients (P=0.67) and post-LT survival at 3 years was 81.1% versus 85.5%, respectively (P=0.008). On multivariate analysis, DCD donor (hazard ratio, 1.38; P=0.005) was an independent predictor of post-LT mortality. However, a survival difference after LT was only observed in subgroups at higher risk for HCC recurrence including Risk Estimation of Tumor Recurrence After Transplant (RETREAT) score ≥4 (DCD 57.0% versus DBD 72.6%; P=0.02), alpha-fetoprotein (AFP) ≥100 (60.1% versus 76.9%; P=0.049), and multiple viable tumors on last imaging before LT (69.9% versus 83.1%; P=0.002). In this analysis of HCC patients receiving DCD versus DBD livers in the UNOS database, we found that patients with a low-to-moderate risk of HCC recurrence (80%-90% of the DCD cohort) had equivalent survival regardless of donor type. It appears that DCD donation can best be used to increase the donor pool for HCC patients with decompensated cirrhosis or partial response/stable disease after locoregional therapy with AFP at LT <100ng/mL.

Post-Cardiac Transplant Survival of Patients Supported by the Heartmate 3 Devices: A UNOS Analysis

Introduction Post cardiac transplant outcomes of patients supported with the Heartmate 3 left ventricular assist device (LVAD) have not been previously reported. The purpose of this analysis was to report status at the time of transplant and survival by continuous flow (CF) device type. Hypothesis Patients supported with a HeartMate 3 LVAD will have a similar post-transplant survival to other contemporary CF-LVADs. Methods The study cohort included adult patients supported on contemporary, continuous flow (CF) devices in the UNOS registry who underwent cardiac transplant between the years 2014-2018, prior to the 2018 UNOS allocation system change. The analysis was limited to patients who underwent initial LVAD implantation in 2014 and beyond to allow post-transplant comparisons among patients with similar LVAD support times. Multivariable cox regression was performed to assess the association between LVAD type and post-transplant survival. Results The study cohort consisted of 3,117 patients who underwent cardiac transplant while on LVAD support (Heartmate 2: 1,545, Heartmate 3: 179, HeartWare (HVAD): 1,393). No patients supported on Heartmate 3 devices were transplanted for pump thrombosis during this time period. Patients supported on the Heartmate 3 were less likely to be listed 1A for complications at the time of transplant (Heartmate3: 28 % (51/179), Heartmate 2: 44 % (680/1,545), HVAD 37 % (511/1,393, p Conclusions Patients supported with Heartmate 3 LVAD at the time of transplant have similar survival after transplant compared to other contemporary CF devices in this early experience. No patients with a Heartmate 3 were transplanted for device thrombosis.

Time for evidence-based, standardized donor size matching for pediatric heart transplantation

BackgroundAccurately predicting cardiac size by other body parameters has long been problematic to determine whether a donor heart will serve a given waitlist candidate, yet hundreds of heart donors are turned down annually for size mismatch. ObjectivesWe sought to describe how donor body weight parameters are currently utilized in cardiac transplantation and its influence on waitlist outcomes. MethodsFrom the United Network for Organ Sharing database, pediatric (age <18 years) heart transplant candidates were divided into lower quartile, interquartile, and upper quartile categories based on final maximum acceptable donor–candidate weight ratio (DCW), expressed as percentage. Baseline characteristics and waitlist outcomes, including monthly offers/candidate and survival were compared. ResultsOverall median DCW was 200% (range, 159%-241%). Patients with congenital heart disease had higher DCW than those with cardiomyopathy (223% vs 203%; P < .001). Number of monthly offers/candidate (5.0, 5.6, and 7.2, respectively; P < .001) increased with quartile of DCW. Posttransplant survival was similar amongst the groups (log-rank P > .05). Subgroup analysis of critically ill children showed a waitlist survival advantage in those listed with a DCW ≥200% (P < .001). ConclusionsDespite substantial practice variation in acceptable donor weight in pediatric heart transplantation, patients listed with variable DCW had similar posttransplant survival. However, in critically ill patients, higher DCW was associated with greater waitlist survival. Better understanding of the importance of donor weight could reduce practice variability and improve organ use and waitlist outcomes for pediatric cardiac transplant candidates.

Implication of Ventricular Assist Devices in Extracorporeal Membranous Oxygenation Patients Listed for Heart Transplantation.

The new allocation criteria classify patients on veno-arterial extracorporeal membranous oxygenation (VA-ECMO) as the highest priority for receiving orthotopic heart transplantation (OHT) especially if they are considered not candidates for ventricular assist devices. The outcomes of patients who receive ventricular assist devices (VADs) after being listed for heart transplantation with VA-ECMO is unknown. We analyzed 355 patients listed for OHT with VA-ECMO from the United Network for Organ Sharing database from 2006 to 2014. Univariate and multivariate Cox proportional-hazards models were used to determine the contribution of prognostic variables to the outcome. Thirty-three patients (9.3%) received VADs (15 dischargeable, 7 non-dischargeable VADs). The VAD and non-VAD groups had similar listing characteristics except that the VAD group were more likely to have non-ischemic cardiomyopathy (48.5% vs. 25.2%), and less likely to be obese (6.1% vs. 25.2%) or have a history of prior organ transplant (3% vs. 31.1%). Patients who underwent VAD implantation had more days on the list (median 189 vs. 14 days) compared to the non-VAD group. Amongst the patients who had VADs, (25/33) 75.5% patients were subsequently transplanted with similar post-transplant survival compared to the non-VAD group (72% vs. 60.5%; p = 0.276). Predictors of one-year post-transplant mortality included panel reactive antibodies (PRA) class I ≥ 20%, recipient smoking history, increased serum creatinine and total bilirubin. Therefore, a small proportion of patients listed for transplantation with VA ECMO undergo VAD implantation. Their waitlist survival is better than non-VAD group but with similar post-transplant survival.

Mitigating the Impact of Gender Mismatch in Heart Transplantation Using BMI and BSA Ratios

Purpose Heart transplantation is limited by the supply of donor organs. Previous studies have associated donor/recipient gender mismatch with decreased post-transplant survival and increased rates of primary graft dysfunction. We evaluate whether this risk can be mitigated. Methods We performed a retrospective analysis of the OPTN/UNOS registry encompassing years 1987 to 2018 for all male adult recipients (>18 years) who underwent isolated heart transplantation with grafts from female donors. Comparison was made to transplants from male donors. Recipients were primarily stratified into two groups, those with BMI less than or greater than donor BMI. Patients were stratified by BSA on secondary analysis. Kaplan-Meier analysis was used to estimate survival post-transplant. Cox Proportional Hazards modeling was performed to identify independent predictors of survival. Results A total of 8,232 candidates met inclusion criteria. Male recipients receiving hearts from higher BMI female donors were more likely to be in the ICU pre-transplant (39.5% vs 36.6%, p = 0.001), on IV inotropes at listing (35.7% vs 33.0%, p = 0.013), and were less likely to have a history of diabetes (21.4% vs 23.9%, p = 0.012). On Kaplan-Meier analysis, recipients transplanted with hearts from higher BMI female donors had improved overall survival. When stratified by BSA (Figure 1), male recipients transplanted with hearts from higher BSA female donors had similar post-transplant survival as male recipients who received hearts from male donors. On Cox Proportional Hazards analysis, increased donor BMI/BSA relative to recipient BMI/BSA remained an independent predictor of improved survival (p < 0.05). Conclusion Prior studies have associated transplanting hearts from female donors into male recipients with decreased post-transplant survival. In this study we have demonstrated that this may be mitigated by matching grafts from female donors to male recipients with lower BMI and especially BSA. Heart transplantation is limited by the supply of donor organs. Previous studies have associated donor/recipient gender mismatch with decreased post-transplant survival and increased rates of primary graft dysfunction. We evaluate whether this risk can be mitigated. We performed a retrospective analysis of the OPTN/UNOS registry encompassing years 1987 to 2018 for all male adult recipients (>18 years) who underwent isolated heart transplantation with grafts from female donors. Comparison was made to transplants from male donors. Recipients were primarily stratified into two groups, those with BMI less than or greater than donor BMI. Patients were stratified by BSA on secondary analysis. Kaplan-Meier analysis was used to estimate survival post-transplant. Cox Proportional Hazards modeling was performed to identify independent predictors of survival. A total of 8,232 candidates met inclusion criteria. Male recipients receiving hearts from higher BMI female donors were more likely to be in the ICU pre-transplant (39.5% vs 36.6%, p = 0.001), on IV inotropes at listing (35.7% vs 33.0%, p = 0.013), and were less likely to have a history of diabetes (21.4% vs 23.9%, p = 0.012). On Kaplan-Meier analysis, recipients transplanted with hearts from higher BMI female donors had improved overall survival. When stratified by BSA (Figure 1), male recipients transplanted with hearts from higher BSA female donors had similar post-transplant survival as male recipients who received hearts from male donors. On Cox Proportional Hazards analysis, increased donor BMI/BSA relative to recipient BMI/BSA remained an independent predictor of improved survival (p < 0.05). Prior studies have associated transplanting hearts from female donors into male recipients with decreased post-transplant survival. In this study we have demonstrated that this may be mitigated by matching grafts from female donors to male recipients with lower BMI and especially BSA.

Non-Infant, Single Ventricle Patients Enjoy the Same Post-Transplant Survival as Other Congenital Heart Patients

Purpose Prior database studies have grouped pediatric transplant recipients broadly into “congenital heart disease” but have not distinguished between single ventricle (SV) patients and other diagnoses. By combining databases, we investigated whether SV patients could have similar post-transplant survival as biventricular (BiV) patients. Methods The UNOS database, providing patient outcomes, was combined with the Pediatric Hospital Information System (PHIS) database, used to elicit specific congenital diagnosis for patients transplanted at a PHIS hospital from 2006-2018. The most complex or diagnosis indicating SV physiology by ICD-9 diagnostic code was used to establish the primary diagnosis. Diagnoses were described and post-transplant outcomes compared by Kaplan-Meier analysis. Results There were 1,803 patients identified with congenital heart disease undergoing transplantation. Diagnoses were identified 1,031 (57%) identified as SV pathology, 706 (39%) as BiV pathology, and 66 (4%) as indeterminant. Only 78 (4%) patients were >18. Though 1-year survival was worse for SV diagnoses compared to biventricular (84% vs 91%; p-value 0.05. When stratified by age, SV infants (n=402) had worse long-term survival compared to BiV (log-rank p=0.038), however, non-infants (n=629) remained the same (p=0.405) as seen in Figure 1. Conclusion Although early survival is worse, overall SV patients are expected to enjoy equally excellent long-term survival after cardiac transplantation as other congenital heart disease patients. However, long-term survival for infant SV is inferior to infant BiV patients, primarily due to mortality within the six months.

The Accuracy of LAS in Predicting Post-Transplant Risk of ECMO Recipients

Purpose Over the past decade, the utilization of venovenous extracorporeal membranous oxygenation (VV-ECMO) as bridge to lung transplantation has increased substantially in the US. There is no discrete variable within the LAS calculation for VV-ECMO support, and therefore current policy is to treat VV-ECMO recipients as being mechanically ventilated with 100% oxygen. However, it is unknown if this adjustment adequately captures the post-transplant risk of VV-ECMO. Methods Scientific Registry of Transplant Recipients (SRTR) data on adult lung transplant recipients 2006 to 2016 was collected. We used 1:1 nearest-neighbor matching to identify non-ECMO transplant recipients with similar LAS post-transplant survival measures as VV-ECMO recipients. After matching we compared transplant-free survival between the groups. Results During the study period, there were 18,924 lung transplant recipients and 592 (3.13%) received VV-ECMO prior to transplant. The mean LAS post-transplant survival measure was similar in VV-ECMO recipients and matched non-ECMO control group, 278.2 +/- 33.3 days vs. 280.3 +/- 32.7 days (p=0.30). Observed post-transplant survival was significantly different between VV-ECMO and matched non-VV-ECMO patients (Fig, p = 0.03 by log-rank test), hazard ratio for death in VV-ECMO recipients was 1.30 (95% CI 1.05 - 1.54). Survival was significantly lower at 90-days post transplant in the VV-ECMO group (86% vs. 94%, p Conclusion The LAS calculator overestimates post-transplant survival in VV-ECMO recipients, especially in the first 90-days. Treating VV-ECMO support as equivalent to mechanical ventilation with 100% oxygen may underestimate the degree of post-transplant risk. The addition of VV-ECMO to the LAS calculation may improve assessment of post transplant survival and lead to more optimal organ allocation and better patient outcomes.